| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
4,725 |
910 |
$125K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,647 |
544 |
$122K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,083 |
443 |
$103K |
| D1120 |
Prophylaxis - child |
2,257 |
2,226 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
2,610 |
2,583 |
$73K |
| D0145 |
Oral evaluation for a patient under three years of age |
512 |
504 |
$67K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,216 |
3,015 |
$65K |
| D1110 |
Prophylaxis - adult |
990 |
980 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,283 |
3,241 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,322 |
1,306 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
3,323 |
3,259 |
$39K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
242 |
44 |
$32K |
| D0272 |
Bitewings - two radiographic images |
1,172 |
1,159 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
790 |
765 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
323 |
317 |
$21K |
| D9248 |
|
140 |
136 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
69 |
26 |
$5K |
| D0160 |
|
135 |
129 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
80 |
78 |
$2K |
| D0350 |
|
146 |
140 |
$2K |
| D1330 |
|
142 |
136 |
$2K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$170.00 |
| D0270 |
|
13 |
13 |
$69.90 |
| D0602 |
|
1,184 |
1,167 |
$9.00 |
| D0601 |
|
1,051 |
1,037 |
$0.00 |
| D0603 |
|
1,631 |
1,608 |
$0.00 |